The human spine extends from the skull to the pelvis and is the primary structural component of the body. It consists of 33 bones (vertebrae) stacked in a vertical column held in place by a complex assortment of back muscles, ligaments and tendons. The spinal column serves to (1) protect the spinal cord and the 31 pairs of nerve roots that branch off the spine; (2) provide stability and support for the head, chest and shoulders allowing the body to stand and walk upright; and, (3) and enables flexibility and mobility of the upper body. Adjacent vertebrae are separated by a fibrocartilaginous disc that serves as a shock absorber by cushioning the stress forces placed on the spine when the individual walks, runs or jumps. The intervertebral discs account for one-quarter to one-third of the spine’s length. The hollow center of the vertebrae create a canal or tunnel that houses a collection of nerve fibers known as the spinal cord, which originates at the base of the brain and ends at the first lumbar vertebra. The spinal cord and the brain are the primary components of the central nervous system.
The vertebrae of a healthy spine can withstand considerable pressure, but when the compressive force being applied exceeds the load limit of the bone, one or more vertebrae can collapse causing a decrease in the intervertebral space and the height of the vertebra. This is usually accompanied by a vertebral compression fracture that is most commonly located in the thoracic spine (primarily at T7-T8 and T12 and L1 – the thoracolumbar junction). Vertebral compression fractures can also be caused by trauma to the spine as a result of (1) automobile accidents, falls, sports injuries or improper lifting of heavy objects; (2) localized infection of the bone (osteomyelitis); (3) cancer in the vertebra that has metastasized from the liver, colon, prostate, breasts or lungs; or, (4) long-term use of steroid medication.
The most common cause of compressive spinal fractures is osteoporosis. In the U.S. alone, it is estimated that this bone-weakening, metabolic disease is the cause of between 750,000 and 800,000 vertebral compression fractures annually. If the osteoporotic or other type of compressive fracture impacts the spinal cord or nerve roots the individual usually experiences acute pain. However, in the case of osteoporosis, more than two-thirds of the fractures are atraumatic (i.e., clinically silent) even though they may occur at several levels of the spine. This means that the individual experiences little or no discomfort from a neurological deficit (the risk still exists that additional compressive fractures may occur). If mild pain does occur it usually goes away within a few weeks. In older patients the pain is often attributed to the natural aging process and is tolerated by the individual without seeking a medical evaluation. Symptoms of a compressive fracture other than pain include loss of body height, pain when standing or walking, evidence of kyphosis (dowager’s hump or humpback at the top of the back which is common in older women), loss of balance, psychological disturbances or neurological symptoms such as numbness and tingling.
If not treated properly vertebral compression fractures can lead to (1) a progressive misalignment, segmental instability and deformity of the spine; (2) loss of body height and mobility; (3) feelings of isolation and depression; and (4) gastrointestinal and pulmonary problems. When an osteoporotic compression fracture occurs in a vertebra, there is a 40% chance that an adjacent vertebra will experience a similar fracture within one year.
In order to diagnose a vertebral compression fracture the spine and neck specialist develops a complete case history, performs a physical examination, and employs imaging technology (x-ray, CAT scan, or MRI) to confirm the presence and severity of the fracture. If a fracture is confirmed, the specialist will usually recommend a conservative course of treatment including rest, over-the-counter and prescription pain medication, and bracing to limit spinal movement. In those cases where the individual is experiencing severe pain, the back and neck specialist may undertake a minimally invasive vertebroplasty or kyphoplasty procedure.
If a vertebroplasty is selected the patient receives a local anesthetic and intravenous sedation. The specialist then uses a fluoroscope to place a trocar (large bore needle) into the collapsed vertebra. Once proper needle placement has been achieved, bone cement (polymethylmethacrylate) is injected under pressure into the vertebra to stabilize the fracture and support the spine. The cement hardens quickly, preventing the fracture from collapsing further while it heals. The procedure, which is usually performed on an outpatient basis, takes less than two hours.
If the kyphoplasty procedure (aka Balloon Assisted Vertebroplasty) is selected, the specialist inserts two fluoroscopically guided needles, each containing a deflated balloon, into the vertebra. The balloons are then inflated to increase the height of the vertebra. After the balloons are deflated and removed, bone cement is inserted into the space created by the balloons. Patients usually experience immediate pain relief with either procedure. Complications following vertebroplasty or kyphoplasty are extremely rare. However, there is a very slight risk that the cement will leak, causing pressure on the spinal nerves. In addition, numbness, tingling and infection at the injection site have infrequently been reported.
In some instances, the patient’s intractable pain and imaging studies showing a severe fracture may indicate that open surgery is necessary. In this case, the back and neck specialist may elect to fuse the vertebrae and/or insert spinal instrumentation (plates, rods, hooks, pedicle screws, or cages) to stabilize the spine.
Patients with any one of the following should not undergo a vertebroplasty or kyphoplasty:
- There has been a greater than 80 percent collapse of the vertebra
- Osteomyelitis or discitis is present in the vertebra
- The compression fracture has been present for more than one year
- There is spinal curvature (scoliosis or kyphosis) that is due to causes other than osteoporosis
- There is spinal stenosis or herniated discs with nerve or spinal cord compression and loss of neurological function not associated with the compression fracture
- The patient has coagulopathy (a disease or condition affecting the blood’s ability to coagulate)
- There has been significant compromise of the spinal canal caused by an impeding bone fragment or tumor
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